The new King's Fund report Clustering of unhealthy behaviours over time shows that between 2003 and 2008, health interventions to reduce smoking, excessive alcohol use, poor diet and inactivity actually had the effect of widening inequalities in health.
The report showed that for the four risk behaviours the authors observed – together responsible for about 50% of preventable morbidity and mortality – those in higher socioeconomic groups changed their behaviour more than those in lower socioeconomic groups.1 To reduce health inequalities, the report recommends putting a focus on reducing the risk behaviours of the poor. The King's Fund report identifies the GP practice as well placed to do this.
GPs in deprived areas are already trying to reduce these risks – but it's not easy. I've been a GP in one of the most deprived wards in one of the most deprived boroughs in England for about 20 years, and we have made huge efforts to help our patients reduce their unhealthy lifestyles – from organising healthy walks to providing advice on diet and smoking cessation, to handing out free pedometers and offering an on-site alcohol counsellor. But although there have been some individual success stories, the overall impact of our efforts has not been impressive.
The King's Fund report says GPs should be incentivised to reduce unhealthy behaviours in their patients, suggesting what has been lacking is our motivation. Yet there is evidence that crude ‘pay for performance' incentives can actually undermine motivation, as Pulse covered last month.2 It can also alienate patients.
I saw a woman the other day who suffers from dreadful chronic pain and depression. I noted she was only using one of the three antihypertensives we had prescribed. I asked her why, and she said: ‘I got fed up with you doctors always going on about my blood pressure and ignoring the things that really mattered to me.'
I felt ashamed – we have all been swept up by QOF, and she had a point. But if we really want to talk to people about health, then we need time.
So while I am against QOF incentives, I am in favour of providing resources such as funding for the extra time and staff needed to tackle these issue. We could reintroduce deprivation payments as well, for instance, or offer payments for longer consultations. Practices that offer 15-minute consultations could be paid to employ extra doctors or more practice nurses, healthcare assistants or health trainers. It's not just more time that's needed – we also need to create better continuity of care in general practice. I have no simple answer to this challenge, but we must address it.
There are other issues around lifestyle that need to be addressed at a national level. For example, we know that poverty increases the stress people face every day. If people are living very stressful lives, it is hard to give up immediate pleasure and stress relief in return for the promise of a longer, healthier life. As the Marmot report acknowledges, reducing health inequalities means tackling the wider social determinants of ill health.
This is where a vital role for the GP comes in – not in earning a few extra QOF points for ticking some boxes, but in being advocates for our patients. Health advocacy, as Dr Jonny Tomlinson recently wrote in his blog, means doctors trying to influence the social determinants of ill health – not just changing patients' behaviour.3 The GPs at the Deep Endproject in Scotland is an inspiring example of how this works in practice.4
Our contribution as GPs will not be effective if the other factors underlying health inequalities are ignored. We GPs should do more to challenge Government policies; income disparity is widening, welfare cuts will hit the poorest the hardest and youth unemployment is at shocking levels. We should push for Government action to reduce poverty, invest in education – especially in the early years – and for young people to stay longer at school, in economic policies that create jobs, and in better housing with planning that supports community development and reduces social isolation. We also need the Government to tackle the corporate promoters of alcohol, smoking and unhealthy eating.
If we are serious about improving the health of the poorest, we need to look beyond individual behaviour change and address the factors that maintain health inequalities.
Dr Louise Irvine is a BMA Council member and a GP in Lewisham, south-east London
References
[1] King's Fund. Clustering of Unhealthy Behaviours over time. 2012. http://www.kingsfund.org.uk/publications/unhealthy_behaviours.html(accessed 29 August 2012
[2] Iacobucci G. Financial incentives for GPs ‘undermine motivation'. Pulse 2012. http://www.pulsetoday.co.uk/newsarticle-content/-/article_display_list/14452383/financial-incentives-for-gps-undermine-motivation(accessed 29 August 2012)
[3] Tomlinson J. Medical advocacy. A Better NHS 2012 http://abetternhs.wordpress.com/2012/08/18/medical-advocacy/(accessed 26 August 2012)
[4] Glasgow University. GPs at the Deep End. http://www.gla.ac.uk/researchinstitutes/healthwellbeing/research/generalpractice/deepend/ (accessed 31 August 2012)
